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Disappointing neighbouring dinner talk


Guest Kirsteen

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Guest Kirsteen

Hi there,

 

I just returned from a wee night out at a favourite restaurant here in TO. Seated next to my table, as I discovered, were two gentlemen, either senior residents (my first guess) or youngish attending doctors from a city-centre, Toronto hospital. One of the guys just happened to mention that they had just selected two people to fill a couple of positions--which residency, I'm not sure. (Could this be plausible: that some Canadian residency positions could already be filled on the residency Director side, i.e., could they have already selected their match lists at this point?) In any case, it was a little disappointing to hear the views of one of them.

 

Basically, he was talking about the selection process that he favours for residents. He mentioned that he generally detests the thought of hiring any women since he really likes to, "...just sit around and shoot the s*** with the guys on shift, and you just can't do that with a woman." "Besides," he added, "...trying to deal with their requests of maternity leave is a nightmare. You end up being short-shifted and worked to the bone, and we're already at each others' throats because we don't have enough personnel." Furthermore he added, "Well, I didn't get my way anyway as we ended up picking one guy and one woman, although she doesn't seem too bad. She at least had a few intelligent things to say. Also, I guess it looks better politically if we hire at least one of them."

 

Ugh. I don't consider myself a feminist, I'd much rather promote harmony between the sexes, but overhearing the above was slightly tough and disappointing. :\

 

Cheers,

Kirsteen

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Guest Ian Wong

The reality is that mat leave can really screw up a residency program, particularly in one with small numbers of residents. As a hypothetical example, if your program took two spots a year, then there are 10 residents in that specialty in the city (assuming your standard 5-year residency). For example, to pick a random residency to highlight this, U of T's Plastics program takes 2 a year, and trains them for 5 years (there's no mandatory research year).

 

At first glance, with 10 residents in that field, it sounds like you could have a very cushy on-call schedule with each resident taking one night call in every 10 days (ie. q10 call). However, that's not really the case, and that's why a resident away on mat leave can really mess up the call schedule for the remaining residents. What follows is a hypothetical call schedule, and not necessarily what actually happens.

 

Generally, the first year residents are doing off-service rotations (ie. a first-year Plastics resident actually does little to no Plastics in that year, but rather spends time on General Surgery, ICU, Internal Medicine, Emerg Medicine, etc). So, you can delete the first years from the call schedule. That leaves 8 residents in that specialty to take call.

 

The second year residents are also doing off-service rotations, although they may well get some more Plastics exposure than the first-year residents, but since you don't start doing dedicated Plastics full-time until your PGY-3 year, we'll be a little excessive and also delete them from the call schedule. That leaves 6 residents in that specialty to take call.

 

Now, the two chief residents in PGY-5 have slogged their way through the full surgical residency, and their major priority is to get as much OR exposure and log as many cases as possible, while also studying for Royal College exams. They get placed on second call, which means that there must always be a junior resident on call with them (the chief only gets paged as a "backup" person in case the junior resident can't handle that issue). That redundancy effectively drops them out of the "first call" pool roster. That leaves 4 residents in that specialty to take (first) call.

 

Just looking at the U of T Plastics site on CaRMS, they mention that there are 6 different teaching hospitals providing Plastics exposure. Now, many of these might be smaller hospitals that don't require resident coverage, but the bottom line is that you've only got 4 Plastics residents to take first call to cover all the hospitals that DO require resident coverage. That's q4 call to cover all of the hospitals, and if a hospital is big enough that it requires its own on call team, then that would mean splitting the call roster into two teams that would then be pulling q2 call(!).

 

Off course, to balance this out (because q2 call breaks all sorts of residency contracts), you will also have off-service residents rotating on the Plastics service (ie. ENT residents spend time on Plastic surgery, as do General Surgery residents and a host of other surgical specialties), but your Plastics residents also might be away because they are ill, are doing a research elective, or are on vacation. With each resident being guaranteed 4 weeks of vacation annually, that means that each resident is actually only working 11 of the 12 months, despite the fact that patients need help 24/7/365.

 

As a result, if a member of your Plastics team has to take mat leave, that can really leave a big void that results in every other person on that service (and there aren't that many of them) having to pitch in with extra on-call shifts, and this can very quickly breed resentment that will mess up the team, particularly if that's either not the first baby she's had, or if she's not the only resident on the service who's had a baby. Either the other residents need to go from being on call q4 to q3 or else the attendings themselves need to pitch in and take first call. Neither option is a fun one to explore! :)

 

It's for this reason that those illegal questions pop up ever so often on residency interviews. It's not because the program directors love breaking rules because it's fun, but rather because they've all seen or experienced firsthand, what can happen when you lose the services of one or more of your residents for an extended time period, and they wish to avoid that scenario even if it means compromising the interview process.

 

I don't necessarily condone the practice of asking these questions at interviews, but the CaRMS process is a lot messier than what it appears to be at first glance.

 

Ian

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Guest Ollie

Parental leave benefits are extended to both mothers and fathers for up to a year combined. So a new father could easily be away on leave for as long as new mother. I wonder how many men are asked about their intentions to have a family and/or take parental leave? It's a little scary that these two men were talking so openly about this in a public place, considering that it is illegal to not hire someone based solely on their intentions to have a family. I think it had been discussed in another thread about how residency programs may have to adjust to the increasing numbers of women MDs, and the fact that increasing numbers of men take advantage of parental leave benefits. Should be interesting...

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Guest jackiedirks

To restrict a woman from a position because of a hypothetical mat leave that she may never take is ridiculous. Medicine is already enough of an old-boys-club without these archiac attitudes.

 

To put so much increased effort into attracting women into the profession of medicine, citing our compassion and empathy as desirable characteristics, and then to pat us on the head and ship us out to a family med residency is an outdated and terribly contradictory approach. (Not that anything is wrong with family med- its just the principle.)

 

Hopefully by the time I am looking to match I'll be able to find a program without these attitudes.

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Guest UWOMED2005

Yes, there are specialties whose programs tend to be much more open to ideas such as maternity leave. Sadly, these tend to also be the same professions dominated by women. . . it sets up a positive feedback loop and soon that specialty has a majority proportion women (ie more women in a specialty overthrow the old-boys, set-up rules that are favourable to women and as such more female MDs end up choosing that specialty.)

 

The unfortunate thing is that this is turning some specialties into "pink specialties" but leaving others "blue specialties." The pro women's rights actions of the obstetrics or pediatrics resident do little to aid the female med student hoping to match to cardiac surgery.

 

The sad thing is, some/many/most guys are often too lazy and/or stupid to learn how to do basic household chores (sorry, occasionally switching the channel from TSN to HGTV doesn't count.) Nor are we smart enough to have come up with a way to physicall carry the child through pregnancy - so our taking paternal leave in no way obviates the need for women to take maternal leave. This leaves us with the unfortunate fact that a female med student/resident wanting a family must a) take maternity leave to deliver her child (OR adopt OR decide not to have a family) and B) often decide to work part-time while their kids are young (OR be a super-mom and risk burning out OR marry a guy who isn't lazy/stupid and actually knows how to cook/clean/change diapers.)

 

Ian's right. It's not about sexism, political-correctedness, old boys clubs or the like. And to refuse to bring them up or pretend this isn't the case for the sake of political correctness isn't appropriate either. Thing is, with the SYSTEM AS IT IS, having a resident take maternity leave throws a monkey wrench in the work (as would having one quit or die.) As well, the number of family physicians working only part-time (admittedly, this isn't not only women) is a huge part of the family physician shortage today. . . I worked with a family physician who pointed the fact out that if you divided the population of London by the number of active family physicians, you'd get an appropriate number for each family physician to work 40-50 hr weeks. And when you think about it, after spending that much $$ and that many years of training it is a waste to see someone take a few years off and then work 10-20 yrs part-time.

 

But this is not meant to be an attack on women in medicine. . . rather I mean it as an attack on the system itself. The fact maternity leave and part-time is a problem IS THE PROBLEM.

 

Problem is, I don't know how to fix it.

 

Do you?

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Guest mying

Having been on the short end of the stick already in clerkship alone because of my gender, I'm sorry. I don't buy that. Are you also going to say that older applicants should get the chuck because they have less working years ahead of them too? It *is* sexism to make any judgements based on a person's gender, no matter what the reasoning people may think justify it, and to say that it is anything less is to make light of what is a real problem. Perhaps not a problem in isolation, but a problem all the same. Could it not be argued that since male residents are more likely to get into drugs and alcohol during residency, and men are more likely to have heart attacks before the age of 50, maybe you shouldn't take them either? Is this decision to discriminate against family-planning women "evidence-based"?

 

What Kirsteen describes is out-and-out discrimination. There are no excuses for that.

 

The root problem is there isn't enough residency spots or doctors in general. We know how to fix that. We just need the people with the power to do so to come around.

 

The next problem up from that is the sheer subjectivity of the residency match. The old boys club is there in far too many specialties. And it sucks to be on the outside trying to penetrate in when, unfortunately, my slapshot just isn't up to par. And, likely, neither is that of the recent immigrant from Saudi.

 

Regardless of why they THINK they're doing it and whether they THINK they're saving the other residents from having to cover more shifts during maternity or any other such nonsense, ANY discrimination based on gender IS sexism, and nothing less.

 

JMHO, but I stand by it.

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Guest Kirsteen

Hi there,

 

Thanks for discussing this. I think the conversation I overheard helped bring to light the realities of medicine, and the problems. I don't blame the one guy for feeling the way he does, but it's one of those lagging indicators that's disheartening to hear given the reading that I've been doing these days. It points to much work that needs to be done.

 

Lately, I've been reading about the health care system and approaches to its improvement. Unfortunately, I think that our system is a bigger bloody mess than I had originally suspected. However, I'd prefer not to flee to the US or delve my head in a hole made of sand. It would be nice to try to do something to change it.

 

There are huge issues, considerations and implications. For one, I don't feel that enough concerted effort is taking place to create good and effective solutions to our healthcare woes. For years, it's been a piecemeal approach. Indeed, our highly valued, highly Canadian, publicly-administered, universal, portable, comprehensive, and accessible Medicare system has evolved fairly recently via the same piecemeal approach to negotiation between the government and professional bodies. Since we've supposedly been in a health care crisis for the past decade (which, incidentally constitutes 50% of the lifespan of the Canada Health Act), why should it be so difficult to change? Publicly funded health care, itself, has only been around for the past forty years or so. So I ask (in a somewhat nostalgic, Sex and the City-ish way :) ), is this religious fervour for Medicare simply a product of baby boomer insecurity?

 

One of the prevalent, oft-mentioned solutions is to increase the number of residency spots to satisfy demand for physician services. If I was to soon become a medical student, I think I'd favour this approach as it helps me get a job at the end of my undergraduate training. However, this does not seem to be a priority for the government for at least one reason: by limiting the number of doctors produced, they can also limit the payouts for billings, which constitute a huge proportion of most province's health care budgets and whines. This has been a strategy used at least once before, in the past couple of decades by the Tories when they cut the numbers of seats in medical schools.

 

I've been thinking of good ways to try and turn things around. ...and not simply for medical school interview purposes. For one, I think we need to get folks listening to one another, i.e., the doctors and the politicians/bureaucrats. Perhaps it would help to involve or encourage more medical bureaucrats, for a start, i.e., folks who are clinically trained but who are willing to take on organizational and leadership roles? We probably also need better and more consistent ways of evaluating the system. We also need some imaginations to start brainstorming innovative approaches to the problems as opposed to piecemeal ones that build upon an already cracked foundation.

 

The thinking on this end continues, but I'd be happy to hear your thoughts, too.

 

Cheers,

Kirsteen

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Guest Ian Wong
by limiting the number of doctors produced, they can also limit the payouts for billings, which constitute a huge proportion of most province's health care budgets and whines.
The thing is, there's a fixed amount of work available out there. Canada has a finite population, and within each age bracket, a finite percentage of individuals who are going to require medical care at any particular point in time.

 

Barring some acute event like SARS therefore, we are moving a relatively constant number of people through the health care system at any given moment (and in fact, we really don't have the ability to cope with a sudden increase in patient numbers, as was shown in the Toronto SARS epidemic so recently.)

 

If there is a relatively constant number of patients, then there's a relatively constant number of procedures, office visits, medication requirements, specialist consults, etc being demanded by these patients.

 

Under a fee for service model, it doesn't matter if there's 1 physician, or 100 physicians out there seeing each of those patients (each patient encounter generates the same billing from the provincial health plan ie. OHIP), and the government still spends the same amount of money.

 

Just as an example, let's assume that there's a fixed pool of 10 million patients in the province, and each time you as a physician saw a patient, you get to bill OHIP 10 dollars. So, each fee-for-service encounter costs OHIP, and the government $10, and since there are 10 million patients, OHIP stands to pay $100 million for all these patients to be seen.

 

It's just that if there's only 1 physician seeing all the patients, then he/she is making like $100 million, whereas if there's a pool of 100 physicians to spread the workload, then each of them would only be performing and billing for $1 million apiece. Either way, the government sees a net loss of 100 million dollars. So, if you increased the number of physicians, in theory the government wouldn't be spending any more money (it's not like if you increase the number of physicians that the number of patients also simultaneously increases; the two factors should be quite independent of each other), it would just mean that each of those physicians would make less money because the workload is distributed among more doctors.

 

Having said that, in a different sense, you're right, as medical personnel is the limiting reagent in whether a medical procedure gets done. When a patient's surgery is cancelled due to "lack of beds", it isn't because there are physically no more beds in the hospital (you can always find room to stick a patient somewhere), but rather that there aren't enough nurses to properly monitor extra patients. When your surgeon has to stop operating at 3:00 pm, instead of adding in a couple more cases and stopping at 5:00 pm, that's because again, either they've reached their capacity to handle those patients post-operatively, or because there's no money to pay for extra OR time in the form of more medical supplies, more OR nurses, etc (your expenditures that day have hit whatever cap was placed upon them by the hospital administrators).

 

Waitlists are a sign that the system isn't moving patients through as quickly as new patients are being generated, particularly given the universal trend that waitlist times are ever increasing. Has anyone ever heard of waitlist times improving??? Hopefully it will happen at some point, because the progressive elongation of waitlist times isn't a process that can continue indefinitely...

 

The trouble is that as Canada advances so that a larger proportion of the population hits the older age brackets (as all our baby boomers hit their 60's and 70's), they will become seriously heavy users of our healthcare system. If you think things in Canadian healthcare are underfunded now, or that our current physician shortage is bad, just wait until all those baby-boomers are out demanding health services, and all those baby-boomer physicians have retired! It's going to be an interesting ride over the next 10-15 years.

 

Ian

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Guest UWOMED2005

Yeah, I wasn't looking for excuses for that conversation. It might not have been readily apparent in my last post, but I'm disgusted by that viewpoint as well. Gender definitely shouldn't be a basis for discrimination.

 

My point was not to excuse such attitudes, but to delve into WHY those attitudes exist. To just gloss over the reasoning behind them is wrong as well. There's a lot more doctors out there who might feel the same way (or feel the opposite) but having people afraid to even discuss such matters for fear of being labelled sexist isn't going to help either!

 

Really, part of me is wondering whether either gender should be allowed to have a family in medicine.* Most jobs easily fit into a 9-5pm workday. Many to most things in medicine cannot: if a patient presents to emerg with a ruptured AAA you can't just tell them to go home and come back after the vascular surgeon has dropped his/her kids off at school! Not to mention the length/cost of training requires society to maximize the return from MDs in terms of hours and patients per MD.

 

I'd argue one of the big stressors on the system today is the lack of availability of some physicians to their patients. . . you often see patients showing up in emerg with stuff that should have been dealt with at the FP's office or a specialist, but the patient had to wait a few weeks and the problem boiled over into a crisis necessitating an emerg visit or even an admission.

 

Monks in the middle ages devoted their lives to God, going without family. What would happen if 21st century doctors were asked to do the same to human health? Is there anyone applying (or in) who would honestly be willing to do that?

 

*Obviously I'm not entirely serious with this whole viewpoint. But I hope you see where I'm coming from!

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Guest Kirsteen

Hi there,

 

Monks in the middle ages devoted their lives to God, going without family. What would happen if 21st century doctors were asked to do the same to human health?

 

Interestingly, in the past month or so, I've heard more than a couple of people's warnings that medicine can be a career of absolute devotion if you allow it to be. That is, if you choose, you can do little else in life aside from medicine and the necessities to keep you living, it can be that encompassing. :)

 

Cheers,

Kirsteen

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Guest UWOMED2005

Yeah, I can attest to that. During the busiest core rotations of clerkship (internal medicine, gen surgery) my life has consisted of going to the hospital, coming home, doing the necessities of life, reading when I don't pass out, and going to the gym/occasional rugby practice.

 

During Internal Medicine I was on call 5/6 weekends. :eek

 

If I decided to keep up that kind of pace during a 30 yr career, I have to admit I've wondered whether it would be a responsible decision to attempt a family.

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Guest everyoneloveschem

The whole situation is sad, sad, sad. Do you turn doctors into some sort of weird queen bees, whose lives are subsumed by medicine, while others cook, clean and raise their children (they may have valuable genetic material to pass on after all!)?

 

Yes, it would be ideal to have a pool of physicians willing to work long hours and flexible shifts, but physicians are people, and I think that most people enjoy their non-working time, which keeps them sane and thus keeps their mental and physical health up, which in turn benefits their work life.

 

I wonder how many people would choose to go into medicine if they were told they would be sterilized upon entrance to med school (I know, a bit extreme, but...)? Unless I was 100% sure that being a physician would make me whole, I don't think I'd sign up.

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Guest UWOMED2005

Yeah, that's basically I was going with that line of thinking - though sterilization would be the extreme end.

 

Questioning whether the quality of physicians isolated from society is extremely valid.

 

I'm obviously not serious bring up the idea of physicians being forced to be celibate. . . but with some of the hours I've worked this year, the idea has popped into my head!

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Guest katwoman2003

My question is: Wouldn't it make more sense to try to make time for ourselves outside of medicine so that we can keep in touch with what being "human" is all about? If we don't have families, friends, or hobbies etc., how will we be able to empathize with patients that we see everyday who do not devote their lives to medicine like doctors do?

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